Provider Demographics
NPI:1801885348
Name:MARK, NICOLE J (DO)
Entity type:Individual
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First Name:NICOLE
Middle Name:J
Last Name:MARK
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Gender:F
Credentials:DO
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Mailing Address - Street 1:5300 W HILLSBORO BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-4395
Mailing Address - Country:US
Mailing Address - Phone:954-794-1360
Mailing Address - Fax:954-794-1367
Practice Address - Street 1:5300 W HILLSBORO BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-4395
Practice Address - Country:US
Practice Address - Phone:954-794-1360
Practice Address - Fax:954-794-1367
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2011-06-29
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Provider Licenses
StateLicense IDTaxonomies
FLOS8649208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265026600Medicaid